i feel so guilty..should i have done more?

rkitty198, BSN, RN · Oct 22, 2009

Minus the hypoxic drive stuff, are you going to let the patient de-saturate into the 70's and say it was COPD?

No, you need some ABG's to evaluate that. One can actually retain oxygen easily, and not perfuse the tissues.

Okay minus where the patient should have gone vs where the patient ended up....Nursing care is the same, ABC's!!!!

Whether or not you know how to read ABG's or EKG's you know how to do what a prudent nurse would do.

The patient was decompensating, you involved respiratory and that was good, you involved the MD great.

What did you see after the treatment of lasix?

Did the patient get any relief? Did she get worse?

You had her for 3 hours...in that time it sounds like she was decompensating...To become unresponsive...

I would have had no problem calling in the MET team, the medical emergency team, which sounds like someone did after you left...

If you have any of the signs of a patient who is decompensating and you did not feel comfortable caring for the patient because you did not feel things were going right then you should always listen to you gut feeling!

Why didnt you call in an emergency response team?

I dont think you pushed anyone over the edge...or pushed them into a worsened respiratory situation. She was already there to begin with.

Did you involve your charge nurse, your Nursing Director, other co-workers?

Look sometimes there are mistakes that happen, and they may not even affect a patient outcome. However, for you to realize where you went wrong is really the first thing. I have walked into nightmares, on my shift. The other day I got report that the patients PICC line was "great." I go in and see that her arm is red, swollen and the dressing is soaked, and she is not on fluids! She ended up with two DVT's in her arm. This Nurse had this patient for 12 hours!

I have had a patient on 6 liters of oxygen, in high-fowlers with 150ml/hr of fluids running with a prior hx of CHF. Swollen all over the place. The night Nurse said she was "fine" just a little wheezy...

I hung dopamine instead of doputamine, pharmacy put the drug in the wrong slot in the pyxis; I beat myself up like mad for that one...thank God the patient was okay. We all make mistakes and errors in judgements.

At least you are re-evaluating what happened, you are looking within to see what you could have done differently, that is the main thing here.

I wouldnt place so much blame on yourself. There is the MD, respiratory and other staff that are also involved, who need to take responsibility.

Take a deep breath, maybe even take a few days off work, spend some free time with family, go out to dinner, relax.

Things will get better :)

aCRNAhopeful · Oct 22, 2009

Isn't the hypoxic resp. drive theory currently being questioned? I was recently taught in nursing school that research is showing that many COPDers actually benefit from higher O2 concentrations. Of course you would want adjust O2 cautiously but could just raising the SpO2 by 4% really be the cause of putting this pt into resp failure? Just raising the question I really don't have an opinion either way since I dont have much experience with these pt's

MamaRN00 · Oct 22, 2009

I think this may be an excellent teaching case. I have a few questions.
erin01 - the very fact that you are questioning yourself and reviewing the care provided, your actions and the doctors inaction - speaks volumes. First, STOP beating yourself up - I understand the guilt issue and I'll guarantee that most of the experienced folks on here have had patients that serve to teach us more than we could ever learn in school.
This is a tough one to admit. In the process of getting "good" at what I do - some of those entrusted to me have paid my "tuition" with their lives. This is not to say that I ever killed anyone - but, there have been things that I did not recognize, treat as aggressively or as quickly as perhaps someone else may have or even that I may have given different circumstances. Even "doing it by the book" does not guarantee a good outcome and some patient presentations are odd, subtle or determined to be a more obvious problem - all the while one "problem" masked another.
We get patients that are sicker and on more medications for more complex conditions than I ever dreamed possible and it is getting worse. Patients are demanding and families unreasonable. Anyone that has even gotten a critically ill patient and the patient be unable to talk or the ever helpful family detail "their history is in their chart - look it up" "they take a round blue pill, 2 small white ones that are football shaped, a yellowish capsule and red capsule and a brownish one with white letters" "their allergies are on file" and then offer that they are "soiled" and need to be changed "right now" when you left the bedside less than 15 minutes earlier - is frustrating. Often this frustration and difficulty is translated into a patient not getting the best of care due to a lack of info or focus.
* I may have made "mistakes" - but, I have never made the same one twice.
* The art of advocacy for your patients is a difficult (often seeming impossible with certain doc's) one. Learning just how far to go is tough. I think it is really hard for newer nurses in some environments (those without "leadership" or those with mobbing or hostility - and most all of us have some element in our workplaces that "restrict" our actions") to speak up about a patient due to being made fun of or being "wrong" and feared to be thought of as incompetent.
Regardless, I will try and help with the clinical explanation. No blame is gonna be here though - it is what it is. As long as you come away from this better than when you went into it - nothing that you did is to be carried as guilt or blame. The sum of all the patients we take care of is what makes great nurses. There is not a single nurse that starts out as a great one - but we all give our patients the best we have. And that makes us great one patient at a time.
?????'s
When you put the patient on the non-rebreather mask - what time did you do it? what was the flow rate of the oxygen? did you call respiratory or consult with your charge that you had a patient "looking bad"?
Did you document the contact with the MD? Did the lasix work? Admitted from the ER - was she given lasix, what did her labs look like/did they do ABG's in the ED? home meds with lasix?
I get the concerns about the tele - but, it is just a monitoring tool. AT first glance, I'd say this is a chronic COPD patients with poor reserves and it does not take too much to push these patients into respiratory failure. Even without doing ANYTHING this patient may have been tiring out from the increased work of breathing and be headed toward a vent or critical care respiratory interventions depending on what she had left. These patients care be really sick and decompensate quickly.
And the fabled "hypoxic drive" is real but, depriving a hypoxic patient oxygen in the short term just guarantees a hypoxic patient and all that goes with that. Sure, these patients live in a mildly hypoxic state and adapt - but the point is they have very little reserves. Difficult patients to manage in some cases - sounds like your patient was sick.
:angel:

VERY well said. I am in my last quarter of RN school and you made us "newbies" feel like we can become good nurses.

kanzi monkey · Oct 23, 2009

So at 3am i get an admission, i work on a step down tele unit. I was told that this is a med surg patient but no more med beds available. I look at the chart before getting report and see she is adm with sob and has hx of copd but no real cardiac hx. in the er her sat was 87%. caridac enzymes were done. So i ask to check the order and make sure they dont want a tele. When i get the patient she is tachy 103, and o2 on 5L 84% so i put her on a vent i mask 50% and get her to like 90, and she looks like she is having trouble breathing. I call the md make him aware that i have now put her on a non rebreather and verify he still doesnt want her on tele. HE says no he thinks its pneumonia, and gives her another does of lasix ivp. Well to some this up by 6am she was non responsive so i call again and we get stat abgs, chest xray...yada. She is reataing o2!!!!! so they put her on bypap. by this time it was 7am and i gave report and let the day nurse what went down, everyone said i did what i could. But just before i left they called a rapid because she now was worse=( I just feel like maybe i should have just told the dr i was putting her on tele and not asked! But i am rn not an md...and he is the one who admitted her! Should i have spoke up more? what could i have done differently?

The doctor should have been at the bedside and ABGs should have been drawn in the ED, I think (with her history and admitting dx). Did she have an EKG?

(I haven't read any responses yet, so I apologize if I'm repeating anything)

erin01 · Oct 23, 2009

when i got the patient she did not good either just at first glance, she was on nc 5l and her pluse ox when i took was 87, so i tried a venti mask ...kept adjusting every few mins because it was not bring up her o2 sat. I was trying to put her back on the venti when she really start to look worse. my plan was to get her anitbx and lasix in and try to get her back on the venti mask. I was in the room a lot very concerned. I called resp and they came up when she was on the venti and said she wasnt wheezing so a tx would not be helpful. I documented everything i did... i think i should have document more!!!!!!!!!!! But i was so exhausted and upset i could not think strait=( I HAVE LEARNED IS ALL I CAN SAY RIGHT NOW.

PostOpPrincess, BSN, RN · Oct 23, 2009

For a new nurse, you didn't do too bad. You will learn from this...

The next time, you get a "gut feeling" something is wrong, pull an MD from ER or intensivist and let them assess.

You did what you could with what you know.

You will see as you grow with experience, things do become "patterned" and "repeated" to the point where you tell the doctor, "this patient needs to be tubed, and vented. I am sending her to ICU....etc.,"

Don't beat yourself up too much, let it go...

=)

questionsforall · Oct 23, 2009

You will learn these things as you go along. Your patient needed Bipap (and maybe even intubation like all other COPD patients who get pneumonia). You did a good job keeping on top of things and following up with the doctor.

drgnflydggr · Oct 23, 2009

Unfortunately, Nyteshade is correct. With COPD, you have to be very careful with the O2 because they rely on the higher CO2 to initiate a breath. You bring those sats up, and they stop breathing. This is basic nursing. Conversely, the MD shares some responsibility because you did in fact make him/her aware of the fact you were implementing a non-rebreather. Had he/she been on the ball, they would have asked more questions, and stopped you. Sorry...hopefully the patient is alright and you have learned a very valuable lesson.

It is my understanding that the drive to breathe in a non-COPD'er is increased CO2. Due to chronic CO2 retention, the drive to breathe in a person with COPD is low O2 levels, and that is why we must be careful when giving O2 to these patients. If we give to much O2, we can suppress their drive to breathe. That is basic nursing.

catshowlady · Oct 23, 2009

It is my understanding that the drive to breathe in a non-COPD'er is increased CO2. Due to chronic CO2 retention, the drive to breathe in a person with COPD is low O2 levels, and that is why we must be careful when giving O2 to these patients. If we give to much O2, we can suppress their drive to breathe. That is basic nursing.

Thank you, WI Student - you took the words right out of my mouth. Agree w/ NREMT-P/RN and others that you can't just leave a hypoxic pt hypoxic, though. BIPAP is the best choice to help them blow off CO2 and get those sats up short of intubation.

Here is a more detailed version from an RT's blog that I found. http://respiratorytherapycave.blogspot.com/2008/06/hypoxic-drive-theory.html Explains it better than I could.

erin01 - Don't beat yourself up. You are learning. Next time, you will know better. I missed the clues, too, with my first pt like the one you had. You kept the doctor in the loop, so you did the right thing by your pt by making him aware of her status.

:paw:

travleur · Oct 23, 2009

It is my understanding that the drive to breathe in a non-COPD'er is increased CO2. Due to chronic CO2 retention, the drive to breathe in a person with COPD is low O2 levels, and that is why we must be careful when giving O2 to these patients. If we give to much O2, we can suppress their drive to breathe. That is basic nursing.

retention, the drive to breathe in a person with COPD is low O2 levels, and that is why we must be careful when giving O2 to these patients. If we

travleur · Oct 23, 2009

It is my understanding that the drive to breathe in a non-COPD'er is increased CO2. Due to chronic CO2 retention, the drive to breathe in a person with COPD is low O2 levels, and that is why we must be careful when giving O2 to these patients. If we give to much O2, we can suppress their drive to breathe. That is basic nursing.

Forum are meant to help people, allnurses.com helps nurses. And, in this case Erin01 was seeking for help.

It is useless to repeat what was already said a dozen of times. I personally think it was useless in the first place to quote school book, like COPD: low-flow oxygen therapy bc low O2 level drive breathing thus causing... blablabla.

In reality, WI student, you'll learn that "basic nursing" won't necessary apply to everyone 100% of the time. Nurses have to think by priority. In this case, as it was mentioned, the priority was a hypoxic pt. You can't just leave a pt with a 84% sat and wait it goes down to 70s, the pt will eventually die. I, also saw pt w/ O2 at 4-5L w/ great ABGs. It obviously depends on what the pt is used to (O2, PEFR at home etc.). Trigerring O2 level are not the same for everybody, there was a lot of studies about it. In practice, student will realize soon enough that there are very few rules or "basic nursing" that apply to everyone.

Erin, believe me, you did nothing wrong. I worked 6 years btw CCU, ICU and ER and i saw quiet a lot of COPD (especially in France bc French smoke a lot! - yes i'm French by the way, that's why my English is not so good).

Anyway, we are human, nobody is perfect, we can't be 100% of our capacity all the time. The NRB, even if not the best choice, was not so bad. A little bit on NRB never killed COPDer (to my knowledge). Again, elevating the poor sat was the priority. If NRB was not the very best it was certainly not the worst. And telemetry would not have helped either.

So go back to sleep, forget about it and learn from it, that's the best thing you can do for your future pt. Just by putting so much thought into it and come here to share it, proved me that you're a good nurse. So please don't quit for that, that won't help anyone. Maybe it's true, maybe telemetry is not the best area for you, or maybe you need some more time to feel a little more confident. I'm sure you'll find your way.

If there is one person who should have hard time to sleep it's the md. This pt should have had ABGs, and X-ray right away. md should know where to stand gaswise w/ COPD. And what's up with the lasix... for suspected pneumonia in a COPD?? pulmonary edema ok but known COPD w/ pneumonia?? ... I don't think so... COPD need proper hydration to liquefy secretion, but hey I might be wrong, I'm not md!

But you don't need to be a md to know that this pt should have received some bronchodilatator and corticosteroid in the very first place, and bipap if necessary (not diuretic!).

Once one sees for the first time the relieve expressed by a COPD once on bipap, he will never forget it, and will think about it everytime he sees a new pt w/ the same condition (quiet frequent, as COPD touches about 15 millions Americans - I just checked!).

Anyway... for student reading this thread, don't forget: COPD + dyspnea: beside low-flow O2 therapy (BASED on ABGs): high fowler position to improve lung expansion, lean over a pillow is usually very helpfull + teach pursed-lip and diaphragmatic breathing. Humidifier if possible, adequate H2O po to liquefy secretion. Anxiety control - this might be the most helpful tip - very frightening condition (it looks like it anyway)! Aerosol of anticholinergic and/or beta2 adrenergic and/or corticosteroid by aerosol or p.o as prescribed. Those are basic nursing that will actually help ALL COPD.

Virgo_RN, BSN, RN · Oct 23, 2009

It is my understanding that the drive to breathe in a non-COPD'er is increased CO2. Due to chronic CO2 retention, the drive to breathe in a person with COPD is low O2 levels, and that is why we must be careful when giving O2 to these patients. If we give to much O2, we can suppress their drive to breathe. That is basic nursing.

I think the current thinking is that while it's true that the normal response to increased PaCO2 is blunted in the person with chronic hypercapnia, the "hypoxic drive" theory is debatable.

That being said, giving a CO2 retainer high levels of O2 will, in theory, cause them to slow their respiratory rate, and thus "blow off" even less CO2, causing their PaCO2 to climb even higher, resulting in CO2 narcosis.

However, from the information provided, it sounds like this patient was really sick, and the nurse did the best she knew how. I think ABGs and CXR should have been done in the ED.

Also, OP, I am confused. You say the patient was retaining O2. Do you mean CO2?